Common use of Expedited Appeal Process Clause in Contracts

Expedited Appeal Process. The Contractor shall establish and maintain an Expedited Appeal Process for Appeals when the Contractor determines or a BHA indicates that taking the time for a standard resolution of an Appeal could seriously jeopardize the Enrollee’s life or health and ability to attain, maintain, or regain maximum function (42 CFR § 438.410(a)). 6.5.1. If the Contractor denies the request for the expedited Appeal and resolution of an Appeal, it must transfer the Appeal to the timeframe for standard resolutions under subsection 8.5 of this Agreement, and make reasonable efforts to give the Enrollee prompt oral notice of the denial and follow up within two (2) calendar days with a written Notice. 6.5.2. Both of the following apply to Expedited Appeal requests: 6.5.2.1. The Action taken on the Notice of Action is for termination, suspension, or reduction of previously authorized behavioral health services; and 6.5.2.2. The Enrollee, the Enrollee’s Authorized Representative, or a BHA acting on behalf of the Enrollee and with the Enrollee’s written consent, may file an Appeal with the Contractor, either orally or in writing, within ten (10) calendar days from the date on the Contractor’s written Notice of Action that communicated the Action. 6.5.3. The Enrollee may ask for continued mental health services pending the outcome of the Expedited Appeal. 6.5.4. The Contractor shall make a decision on the Enrollee’s request for Expedited Appeal and provide written Notice, as expeditiously as the Enrollee’s condition requires, within two (2) calendar days after the Contractor receives the Appeal. (42 CFR § 438.408(b)(3)). The Contractor shall also make reasonable efforts to provide oral notice. 6.5.5. The Contractor shall ensure that punitive action is not taken against a BHA who requests an expedited resolution or supports an Enrollee’s Appeal (42 CFR § 438.410(b)). 6.5.6. The Contractor may extend the timeframe up to 14 additional calendar days if the Enrollee requests an extension or the Contractor can demonstrate that it needs additional information and that the added time is in the Enrollee’s interest. 6.5.7. For any extension not requested by an Enrollee, the Contractor must give the Enrollee written notice of the reason for the delay. 6.5.8. The Enrollee has a right to file a Grievance regarding the Contractor’s denial of a request for expedited resolution. The Contractor shall inform the Enrollee of their right to file a Grievance in the Notice of denial.

Expedited Appeal Process. The Contractor shall 1. MCO must establish and maintain an Expedited Appeal Process expedited review process for Appeals when appeals for situations in which MCO determines, based on a request from the Contractor determines Enrollee or from a BHA indicates provider on behalf of the Enrollee, that taking the time for a standard resolution of an Appeal could seriously jeopardize the Enrollee’s life or health and or ability to attain, maintain, or regain maximum function (42 CFR § 438.410(a))function. 6.5.12. If Expedited appeals are just a “special type” of appeals. MCO is required to follow all standard appeal regulations for expedited requests except where differences are specifically noted in the Contractor denies the request regulation for the expedited Appeal and resolution of an Appeal, it must transfer the Appeal to the timeframe for standard resolutions under subsection 8.5 of this Agreement, and make reasonable efforts to give the Enrollee prompt oral notice of the denial and follow up within two (2) calendar days with a written Noticeresolution. 6.5.2. Both of the following apply to Expedited Appeal requests: 6.5.2.1. The Action taken on the Notice of Action is for termination, suspension, or reduction of previously authorized behavioral health services; and 6.5.2.2. The Enrollee, the Enrollee’s Authorized Representative, or a BHA acting on behalf of the Enrollee and with the Enrollee’s written consent, may file an Appeal with the Contractor, either orally or in writing, within ten (10) calendar days from the date on the Contractor’s written Notice of Action that communicated the Action. 6.5.33. The Enrollee may ask for continued mental health services pending file an expedited appeal either orally or writing. No additional Enrollee follow-up is required. 4. MCO must inform the outcome Enrollee of the Expedited Appeallimited time available for the Enrollee to present evidence and allegations of fact or law, in person and in writing, in the case of expedited resolution. 6.5.45. The Contractor shall make a decision on the Enrollee’s request for Expedited Appeal MCO must resolve each expedited appeal and provide written Noticenotice, as expeditiously as the Enrollee’s health condition requires, within two State-established timeframes not to exceed three (23) calendar working days after the Contractor MCO receives the Appealappeal. 6. (42 CFR § 438.408(b)(3))For any extension not requested by the Enrollee, MCO must give the member written notice of the reason for the delay. 7. The Contractor shall In addition to written notice, MCO must also make reasonable efforts to provide oral notice. 6.5.58. The Contractor shall MCO must ensure that punitive action is not taken against a BHA Provider who either requests an expedited resolution or supports an Enrollee’s Appeal (42 CFR § 438.410(b))appeal. 6.5.69. The Contractor may extend the timeframe up to 14 additional calendar days if the Enrollee requests an extension or the Contractor can demonstrate that it needs additional information and that the added time is in the Enrollee’s interest. 6.5.7. For any extension not requested by an Enrollee, the Contractor must give the Enrollee written notice of the reason for the delay. 6.5.8. The Enrollee has a right to file a Grievance regarding the Contractor’s denial of If MCO denies a request for expedited resolutionresolution of an appeal, it must: a. Transfer the appeal to the standard timeframe of no longer than forty five (45) days from the day MCO received the appeal, b. Give the Enrollee prompt oral notice of the denial (make reasonable efforts) and a written notice within two (2) calendar days. The Contractor shall inform notice should include the Enrollee information listed under Section D. Service Authorizations and Notices of their right to file a Grievance in the Action, of this attachment and Notice of denial.Adverse Action included in Section D of this attachment;

Expedited Appeal Process. 1. The Contractor shall LME must establish and maintain an Expedited Appeal Process expedited review process for Appeals when appeals for situations in which the Contractor determines LME determines, based on a request from the Enrollee or from a BHA indicates provider on behalf of the Enrollee, that taking the time for a standard resolution of an Appeal could seriously jeopardize the Enrollee’s life or health and or ability to attain, maintain, or regain maximum function (42 CFR § 438.410(a))function. 6.5.12. If Expedited appeals are just a “special type” of appeals. The LME is required to follow all standard appeal regulations for expedited requests except where differences are specifically noted in the Contractor denies the request regulation for the expedited Appeal and resolution of an Appeal, it must transfer the Appeal to the timeframe for standard resolutions under subsection 8.5 of this Agreement, and make reasonable efforts to give the Enrollee prompt oral notice of the denial and follow up within two (2) calendar days with a written Noticeresolution. 6.5.2. Both of the following apply to Expedited Appeal requests: 6.5.2.1. The Action taken on the Notice of Action is for termination, suspension, or reduction of previously authorized behavioral health services; and 6.5.2.2. The Enrollee, the Enrollee’s Authorized Representative, or a BHA acting on behalf of the Enrollee and with the Enrollee’s written consent, may file an Appeal with the Contractor, either orally or in writing, within ten (10) calendar days from the date on the Contractor’s written Notice of Action that communicated the Action. 6.5.33. The Enrollee may ask for continued mental health services pending file an expedited appeal either orally or writing. No additional Enrollee follow-up is required. 4. The LME must inform the outcome Enrollee of the Expedited Appeallimited time available for the Enrollee to present evidence and allegations of fact or law, in person and in writing, in the case of expedited resolution. 6.5.45. The Contractor shall make a decision on the Enrollee’s request for Expedited Appeal LME must resolve each expedited appeal and provide written Noticenotice, as expeditiously as the Enrollee’s health condition requires, within two State-established timeframes not to exceed three (23) calendar working days after the Contractor LME receives the Appealappeal. 6. (42 CFR § 438.408(b)(3))For any extension not requested by the Enrollee, the LME must give the member written notice of the reason for the delay. 7. The Contractor shall In addition to written notice, the LME must also make reasonable efforts to provide oral notice. 6.5.58. The Contractor shall LME must ensure that punitive action is not taken against a BHA Provider who either requests an expedited resolution or supports an Enrollee’s Appeal (42 CFR § 438.410(b))appeal. 6.5.69. The Contractor may extend If the timeframe up to 14 additional calendar days if the Enrollee requests an extension or the Contractor can demonstrate that it needs additional information and that the added time is in the Enrollee’s interest. 6.5.7. For any extension not requested by an Enrollee, the Contractor must give the Enrollee written notice of the reason for the delay. 6.5.8. The Enrollee has a right to file a Grievance regarding the Contractor’s denial of LME denies a request for expedited resolutionresolution of an appeal, it must: a. Transfer the appeal to the standard timeframe of no longer than forty five (45) days from the day the LME received the appeal, b. Give the Enrollee prompt oral notice of the denial (make reasonable efforts) and a written notice within two (2) calendar days. The Contractor shall inform notice should include the Enrollee information listed under Section D. Service Authorizations and Notices of their right to file a Grievance in the Action, of this attachment and Notice of denial.Adverse Action included in Section D of this attachment;